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Better outcomes require senior managers' commitment to a strong safety culture in healthcare

As the current caregiver crisis hits a fever pitch, including substantial staffing and burnout challenges, it's more important than ever for healthcare organizations to ensure a strong safety culture and internal alignment on the prioritization of safety. Recent Press Ganey data showed that safety culture is distinctly correlated with overall workforce engagement, and according to our new analysis, it's also clearly associated with safety outcomes, in particular falls with injury. Standing in the way of improving this culture, however, is a disconnect between senior managers and nurses on perceptions of the current state of safety efforts, as well as a desire from nurses for senior managers to improve patient safety focus as part of their work climate. 

The performance of your safety culture influences rates of falls with injury

To achieve the best safety outcomes for patients, an exceptional patient safety culture is required. In a validated survey, Press Ganey measures various aspects of safety culture in the domains of Pride and Reputation, Prevention and Reporting, and Resources and Teamwork. In addition, our NDNQI database has safety outcome measures including falls, pressure ulcers, and central line bloodstream infections. When combining these two data sources from 89 facilities nationally, we found a clear correlation between fall with injury rates and safety culture performance. Organizations with fewer falls with injury consistently had better safety culture performance overall, as well as in the three sub-domains (Figure 1).

Figure 1

safety culture and fall data

The biggest gap in performance (between organizations with higher and lower falls with injuries) is in the Pride and Reputation domain, for the question asking whether "Senior management provides a work climate that promotes patient safety" (Figure 2).

Figure 2

safety culture management differences

To understand this difference in more depth, the data was then segmented by role to see where managers and front-line nurses differ in perceptions of safety culture, particularly since nurses are generally key to fall prevention. The findings were significant-in particular, nurses uniformly rate safety culture questions lower than managers across all three domains (Figure 3). This difference in scores is more stark at lower-performing organizations, with the widest gap again related to "Senior management provides a work climate that promotes patient safety" as well as "Adequate dept staffing."

Figure 3

nurses and managers safety perceptions

Steps leaders can take for patient safety culture transformation

There are several steps that leaders can take to bridge these gaps, and there must be specific accountability at the organizational, manager and staff level. Safety leadership at all levels (including senior leaders, middle managers, and local level leaders) must commit to safety as a core value, and consistently show that dedication through their words and actions. This begins with understanding how safety is currently viewed within the organization, and then using those insights to build an improvement plan.

1. Talk about where perceptions of safety diverge, and why

While senior managers have a view into how many safety events occur within their departments, the numbers only tell part of the story. Front-line nurses and other caregivers see the problems in everyday operations that lead to these events, including unsafe conditions and incidents of "drift"—where subconscious and gradual relaxation of safety standards results in preventable falls, infections, pressure ulcers, or other injuries. It's critical for senior managers to proactively engage with clinicians and caregivers so they grasp the full picture behind the current state of workplace safety and can identify training gaps, critical staffing shortages, and tangible solutions to bridge the perception gap between staff and leadership and achieve zero harm.

2. Implement a robust set of patient safety culture best practices

It's not feasible to reinvent the wheel when creating or improving your safety culture, especially when all workers are overwhelmed by the pandemic. Senior leaders and managers should therefore rely on established best practices:

  • Adopt a zero-harm goal and reinforce with other leaders the need to champion this goal as a top priority.
  • Include safety in your mission and vision statements, and ensure it's among your organization's stated values.
  • Support a fair and just climate that promotes psychological safety, in which all employees are encouraged to speak up when they see an area for improvement or unsafe practices.
  • Ensure a robust and reliable learning system is in place to make sure the organization responds appropriately to errors and learns from them.
  • Thoughtfully implement senior leader rounding, by identifying the cadence at which rounds occur, which leaders will conduct them, what questions will produce the answers and outcomes you wish to achieve, and how to effectively follow up on key issues and concerns.
  • Have daily safety huddles, and similarly plan how they will be run so they're informative and actionable.
  • Design a consistent, repeatable method for assessing and measuring patient harm, such as the HPI SEC and SSER Measurement System for Healthcare, and encourage reporting from all types of events.
  • Make harm visible by sharing lessons from stories of patient harm with employees and communicating benchmarks like "days since last serious safety event" with them.

3. Augment leadership skills

Leadership development and training is essential for ensuring leaders at all levels engage in behaviors that visibly drive a culture of safety. For example, leadership training should include guidance on the 4C's:

  • Connect: connect at a personal level with the individual and share confidence and positive intent
  • Check: review expectations and share facts
  • Concerns: ask "what makes this hard to do" and actively listen to understand
  • Commit: ask, "Can I count on you to do ____ next time?" or say "I commit to _____"

4. Enhance safety event reporting and cause analysis effectiveness

Organizations should continually pinpoint new ways to segment and understand data so that learnings can lead to meaningful action. Press Ganey's High Reliability Platform can support the daily management of events and provide analytics to assess organization-wide safety culture, governance, and processes to prioritize improvements. In addition, Press Ganey's safety consulting and NDNQI offerings can help ensure a highly reliable learning and improvement system.

Establishing a first-rate safety culture is integral to reducing safety events like falls with injury, but it cannot be done in a vacuum. Senior leaders and managers at all levels must show that they are ardent supporters of patient safety, integrating it into the lifeblood of their institutions. Continuous listening to workforce concerns is fundamental to sustained success, and in December, leaders can leverage safety culture pulse capabilities from Press Ganey to keep an ear to the ground.

To learn more about how to improve your safety culture, including how our High Reliability Platform can help, reach out to a patient safety expert.


About the author

As Chief Safety and Transformation Officer, Dr. Gandhi, MPH, CPPS is responsible for improving patient and workforce safety, and developing innovative healthcare transformation strategies. She leads the Zero Harm movement and helps healthcare organizations recognize inequity as a type of harm for both patients and the workforce. Dr. Gandhi also leads the Press Ganey Equity Partnership, a collaborative initiative dedicated to addressing healthcare disparities and the impact of racial inequities on patients and caregivers. Before joining Press Ganey, Dr. Gandhi served as Chief Clinical and Safety Officer at the Institute for Healthcare Improvement (IHI), where she led IHI programs focused on improving patient and workforce safety.

Profile Photo of Dr. Tejal Gandhi, MPH, CPPS